Disseminated Peritoneal Adenomucinosis Associated with a Panperitonitis-Like Onset: Report of a Case

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1 Surg Today (2001) 31: Disseminated Peritoneal Adenomucinosis Associated with a Panperitonitis-Like Onset: Report of a Case Yoshito Kuroki 1, Shunyou Otagiri 1, and Kazuhiro Tsukada 2 1 Department of Surgery, Kamioka Town Hospital, 725 Higashi-machi, Kamioka, Yoshiki-gun, Gifu , Japan 2 Second Department of Surgery, Toyama Medical and Pharmaceutical University, Toyama, Japan Abstract A 59-year-old man was admitted to our department due to a fever of unknown origin. Abdominal ultrasonography and computed tomography showed a large cystic mass in the lower abdomen and a massive amount of abdominal fluid. A laparotomy was performed under a diagnosis of panperitonitis. Diffuse pyogenic gelatinous ascites and a large cystic mass with a grayish wall, and a hard solid lesion in part were found. The microscopic findings of the hard solid lesion showed calcification, osteogenesis, and focal epithelial proliferation in a tiny area consisting of mucinous cells with no significant cytologic atypia. The remaining part of the cystic wall and small cystic lesions were hyalinized, fibrous, or necrotic tissue. Since a total resection of the masses was not possible, the patient received adjuvant chemotherapy with cisplatin followed by the administration of mitomycin C and 5-fluorouracil. An abdominal fistula with the excretion of pyogenic gelatinous fluid occurred, but the patient is still alive and doing well over 2 years postoperatively. The primary site of this tumor could unfortunately not be identified. Key words Pseudomyxoma peritonei Disseminated peritoneal adenomucinosis Benign neoplasm Introduction Pseudomyxoma peritonei (PMP) is an unusual condition in which diffuse collections of gelatinous fluid are associated with mucinous implants on the peritoneal surfaces. 1 There is considerable debate regarding the Reprint requests to: Y. Kuroki Received: July 3, 2000 / Accepted: March 6, 2001 definition, pathology, site of origin, and prognosis to PMP. Many studies of PMP include cases associated with both benign and malignant mucinous tumors of the appendix, ovary, or other organs, and references to benign PMP and malignant PMP can be found in the literature. 2 4 Ronnett et al. 5 separated PMP into two diagnostic categories, namely, disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis (PMCA) according to their detailed study describing the clinicopathologic features of 109 cases. There have been no case reports using the term DPAM, which has been definitely distinguished from the malignant form of PMP in Japan. Furthermore, such a condition associated with a peritonitis-like onset is very rare. 6 We report herein a PMP case in which the characteristic pathological findings seem to be consistent with DPAM associated with a panperitonitis-like onset. Case Report A 59-year-old man had suffered from fever from the middle of January In spite of treatment with antipyretics by a local physician, the fever rose to about 38 C and general malaise continued every day, and he lost about 7 kg of weight. The patient s local medical doctor introduced him to our hospital due to a fever of unknown origin on February 2, The patient had no abdominal subjective complaints such as abdominal pain, and his previous medical history was negative. A physical examination revealed slight anemic conjunctivas, edema on the back of his feet, abdominal bulging with no tenderness, and no muscular defense. A large mass measuring about 15cm in size was palpable in the lower abdomen. Abdominal ultrasonography showed a large cystic mass in the lower abdomen, and massive fluid collection with high echoic spots was extensively observed in the abdominal cavity. Computed tomography also showed a lesion measuring 14 16cm in size

2 Y. Kuroki et al.: Disseminated Peritoneal Adenomucinosis 647 Fig. 1A D. Computed tomography showed a cm sized mass including fluid and air with partial calcification (A), many small cystic lesions (B), and massive fluid collection in the abdominal cavity (C, D) including fluid and air with partial calcification, many small cystic lesions, and massive fluid collection in the abdominal cavity (Fig. 1). Fluoroscopy in conjunction with a gastrographine enema showed extrinsic oppression in the cecum; however, the appendix could not be identified (Fig. 2). The preoperative diagnosis was panperitonitis of unknown etiology. We performed a laparotomy, and found diffuse pyogenic ascites mixed with gelatinous fluid and a large cystic mass with a grayish wall with a calcified hard solid lesion (Figs. 3 and 4). The results of a bacterial culture of the ascites showed Staphylococcus sp. Moreover, there were many small white cystic lesions measuring about 1 3 cm in size including gelatinous fluid, and some of them progressed to the surface of abdominal organs, and thus demonstrated a phenomenon called scalloping (Figs. 3 and 4). However, most abdominal organs such as the intestine, stomach, and appendix could not identified due to severe inflammatory changes and adhesion (Fig. 3). We tried to remove the masses as much as possible, but our efforts were often unsuccessful and many of the masses remained. The microscopic findings of the hard solid mass showed calcification, osteogenesis, and a focal epithelial proliferation in one small area consisting of mucinous cells with no significant cytologic atypia. The remaining part of the cystic wall and the small cystic lesions were hyalinized, while consisting of fibrous or necrotic tissue, and no epithelial proliferation was observed (Fig. 5). The postoperative course was uneventful, and the fever disappeared soon afterward. We began adjuvant intraperitoneal chemotherapy with cisplatin (20 mg/day for 5 days for two cycles) from March 19. After that, a fistula occurred at the surgical wound, and the excretion of pyogenic gelatinous fluid occurred from the fistula. We tried adjuvant intraperitoneal chemotherapy again with cisplatin (50 mg/ week, and repeated twice) from May 25. However, this treatment was not effective, and thus the regimen was changed to a combination of mitomycin C (MMC) and 5-fluorouracil (5-FU). Intraperitoneal administration consisting of 20 mg MMC and 500mg 5-FU on day 1 combined with intravenous drip infusion of 500 mg 5- FU from days 1 to 3 was repeated three times weekly, and the same treatment was thereafter repeated once

3 648 Y. Kuroki et al.: Disseminated Peritoneal Adenomucinosis Fig. 2. Fluoroscopy performed in conjunction with a gastrographine enema showed an extrinsic oppression at the cecum; however, the appendix was not identified more 1 month later. The excretion still continued after 2 years postoperatively; however, computed tomography (CT) showed no significant increase in the remaining tumors. Fistulography revealed that the fistula communicated with the ascending colon via the region between the cecum and ileum. However, this patient s general condition is good, and the performance status is Grade 0. He can presently lead a normal daily life without restrictions except for the fistula. His appetite is good, and his body weight has returned to the same level it was before the onset of the disease. Discussion Pseudomyxoma peritonei (PMP) is a poorly understood condition characterized by mucinous ascites and mucinous implants diffusely involving the peritoneal surfaces. 5 The term was first used by Werth 7 in 1884 who described this disease in patients with perforated cystadenoma of the ovary. In 1901, Fraenkel 8 first described the association of PMP with ruptured mucocele of the appendix. Although there have been numerous PMP case reports, there is still considerable controversy regarding the definition, site of origin, and prognosis of PMP. In the past, PMP was thought to occur from the appendix, ovary, and other primary organs, but in a recent study the primary tumor was found to be an appendiceal adenoma, not an ovarian tumor. 5,6 Recent applications of immunocytochemistry and studies of genetic materials using the polymerase chain reaction have increased the likelihood that most PMP cases are due to metastasis from neoplasms from the appendix. 9,10 In this case, the reason why fluoroscopy in conjunction with a gastrographine enema did not identify the appendix might nevertheless suggest an appendiceal tumor, since the orifice of the appendix was occluded. Postoperative fistulography revealed the presence of a communication with the ascending colon via the ileocecal region. According to these facts, the primary organ was suspected to be the appendix. However, we could not identify the primary organ in this case, because the appendix could not be confirmed at laparotomy and we had no more convincing evidence to determine the primary site. Due to variations in the use of different pathological terms, Ronnett et al. 5 proposed that PMP be defined as a clinicopathological entity characterized by mucinous ascites and noninvasive mucinous implants with a characteristic distribution containing a histologically benign mucinous epithelium derived from an appendiceal mucinous adenoma with a benign clinical course. Cases fitting this definition were to be labeled disseminated peritoneal adenomucinosis (DPAM), whereas similar cases with histologically malignant peritoneal tumors derived from mucinous carcinomas were to be diagnosed as peritoneal mucinous carcinomatosis (PMCA) and were thus excluded from the PMP category because carcinoma-associated cases have a significantly worse prognosis. Sugarbaker 6 also proposed that PMP should be distinguished from mucinous adenocarcinoma with a signet-ring morphology. We consider our present case to be consistent with the DPAM category according to the histological and prognostic features. The common presenting symptoms of PMP are an increasing abdominal girth, ovarian tumor(s), a tumor in a hernia sac, appendicitis, and infertility. 6 This panperitonitis-like onset is very rare; as with this case, less than 1% of all patients are diagnosed due to nonspecific complaints made from the computed tomography scan. 6 It may be inferred that the tumor perforation led to a bacterial contamination in the abdominal cavity. An appropriate therapy for PMP is difficult to establish because of the rarity and heterogeneity of this condition. Surgery is the first-line therapy in all patients in order to remove as many tumor masses as possible, but

4 Y. Kuroki et al.: Disseminated Peritoneal Adenomucinosis 649 Fig. 3. The operative photograph showed a large cystic mass with a grayish wall (left, arrows) and many small white cystic lesions (right, arrows), and some of them had progressed onto the surface of abdominal organs such as the liver; this phenomenon was called scalloping. However, most abdominal organs such as the intestine, stomach, and appendix could not identified due to severe inflammatory changes and adhesion Fig. 4. Photograph of the resected specimen showed a large cystic mass with a grayish wall and several small hard solid lesions (arrow), and many small white cystic lesions measuring from 1 to 3 cm in size including gelatinous fluid in most cases a total resection of the tumor is not possible, and a large percentage of patients thus experience recurrence after the initial surgery. 6,11 Many agents have been tried either as systemic treatment or as intraperitoneal infusions during or after surgery. The most widely used have been 5-FU, cyclophosphamide, MMC, and cisplatin. 1,6,11 Sugarbaker 6 proposed more aggressive surgery during the peritonectomy procedures with heated intraperitoneal chemotherapy. However, most such treatments are only indicated for patients with carcinoma, while no adjuvant chemotherapy has yet been clearly established for DPAM patients with benign characteristics. In our patient, a total removal of the tumor was not possible, and adjuvant chemotherapy with cisplatin followed by 5-FU and MMC was performed. However, the effect of the treatments was not sufficient to eradicate the condition. As a result, a repeated operation will be necessary in the future due to expected complications caused by the fibrosis or adhesion. Although the tumor still remains and continues to be resistant to chemotherapy, it has not increased in

5 650 Y. Kuroki et al.: Disseminated Peritoneal Adenomucinosis Fig. 5A D. Microscopic findings of the hard solid mass (arrow in Fig. 4) showed focal epithelial proliferation in areas consisting of mucinous cells with no significant cytologic atypia in a small area (A), and calcification and osteogenesis in most areas (B). The cystic wall (C) and the small cystic lesions (D) consisted of hyalinized, fibrous, or necrotic tissue, and there was also no epithelial proliferation size, and the patient has been alive and doing well for over 2 years postoperatively. Based on the above findings, a good prognosis for this patient is thus suggested. References 1. Hinson FL, Ambrose NS (1998) Pseudomyxoma peritonei. Br J Surg 85: Hughes J (1967) Mucocele of the appendix with pseudomyxoma peritonei: a benign or malignant disease? Ann Surg 165: Jurgeleit HC (1986) Pseudomyxoma peritonei: a localized benign variant of appendiceal origin. Dis Colon Rectum 29: Sugarbaker PH, Kern K, Lack E (1987) Malignant pseudomyxoma peritonei of colonic origin: natural history and presentation of a curative approach to treatment. Dis Colon Rectum 30: Ronnett BM, Zahn CM, Kurman RJ, Kass ME, Sugarbaker PH, Shmookler BM (1995) Disseminated peritoneal adenomucinosis and peritoneal mucinous carcinomatosis. A clinicopathologic analysis of 109 cases with emphasis on distinguishing pathologic features, site of origin, prognosis, and relationship to Pseudomyxoma peritonei. Am J Surg Pathol 19: Sugarbaker PH (1996) Pseudomyxoma peritonei. Cancer Treat Res 81: Werth (1884) Klinische und anatomische untersuchungen zur lehre von den bauchgeschwuelstein und der laparotomie. Arch Gynaecol 24: Fraenkel E (1901) Uber das sogennante pseudomyxoma peritonei. Munch Med Wochenschr 48: Ronnett BM, Shmookler BK, Diener-West M, Sugarbaker PH, Kurman RJ (1997) Immunohistochemical evidence supporting the appendiceal origin of pseudomyxoma peritonei in women. Int J Gynecol Pathol 16: Cuatrecasas M, Matias-Guiu X, Prat J (1996) Synchronous mucinous tumors of the appendix and the ovary associated with pseudomyxoma peritonei. A clinicopathologic study of six cases with comparative analysis of c-ki-ras mutations. Am J Surg Pathol 20: Hosch WP, Rudi J, Stremmel W (1999) Therapy of pseudomyxoma peritonei of appendical origin surgical resection and intraperitoneal chemotherapy. Z Gastroenterol 37: